Turf Toe Injury - diagnosis and treatment

With the beginning of the NFL season and college football in full swing, I decided to talk about an injury called turf toe which is a common football injury. Turf toe is an injury to the first metatarsophalangeal joint (MTP) that is described as a sprain or tear to the capsule or ligamentous structures.  The American Orthopaedic Foot and Ankle Society defines turf toe as a plantar capsular ligament sprain. (Tewes, 1994)  The anatomy, predisposing factors and causes of turf toe are important in order to understand this sports-related injury.  The diagnosis, treatment and forms of rehabilitation will be illustrated as well as specific complications if left untreated.

            The anatomy of the first MTP joint is fairly complex.  It is a synovial joint incorporating four articulating bones.  They are the first metatarsal, a proximal phalanx, and a medial and lateral sesamoid bone.  The sesamoid bones are located inferiorly and “act as fulcrums to increase the power of the muscles which cross them”. (AthleticAdvisor, 2005)  The first MTP joint is surrounded by a capsule which serves as attachment sights for the abductor hallicus, adductor hallicus and the flexor hallicus brevis on the plantar side.  While the tendon of extensor hallicus longus forms the roof of the capsule on the dorsal great toe. (Dykyj, 1989)  The last muscle in this complex is the flexor hallicus longus which runs between the two sesamoid bones attaching to the distal phalanx.

            The mechanism of injury involves a hyperextension to the first MTP joint which results in capsular damage and or compression to the dorsal articular surface. (Rodeo, 1990)  The shoe or cleat grips hard into the turf, causing the foot to go into forced dorsiflexion during push-off.  The increase in number of cleats on the football shoes leads to increased traction and an increase in incidence of turf toe. (Clanton et al. 1986)  Also, with the foot in this toe-off position, it is common in football for an external force to drive the toe into further dorsiflexion.  Other predisposing factors include increased flexibility of the forefoot, which will allow hyperextension of the first MTP joint.  (Clanton et al. 1986)  Clanton suggests that a stiffened forefoot in the boot of football players sustained less turf toe injuries. (Clanton et al. 1986)  Coker suggested that shoe fit could be a contributing factor, explaining that wider feet require large sized shoes, subjecting the first MTP joint to greater flexion and extension stress. (Coker et al. 1978)  Probably the biggest influence on turf toe injuries is the artificial turf, hence the name of the injury.  Grass has been replaced by turf in the late 1960’s, and the reported incidence of first MTP joint injuries has increased after introducing artificial turf. (Clanton, 1994)  Football athletes are chronically in three-point stances, and require tremendous amounts of power from this position with the foot relatively flat.  This requires excessive dorsiflexion and extension of the first MTP joint. (Sammarco, 1995)   During push-off, the great toe is the last structure in contact with the ground.  Up to eight times a person’s body weight can be transferred through the great toe.  (AthleticAdvisor, 2005) 

            Diagnosis includes questioning the patient with regard to the mechanism of injury.  This will provide information about what structures may be injured.  The patient will report sudden onset of pain after forced hyperextension. (Clanton et al. 1986)  Physical exam will show evidence of swelling, ecchymosis and painful passive ranges of motion. Active ranges of motion of dorsiflexion and plantarflexion in the first MTP may be decreased.  (Bowers, 1976)  When examining the patient, he or she may have an antalgic gait, externally rotating their lower extremity to avoid dorsiflexion during push-off. (Bowers, 1976)  Imaging may be required in severe cases to rule out avulsion fractures on the first metatarsal head or proximal phalanx, or even sesamoid bone fractures. (Churchill, 1998)  It may also be advantageous to assess any articular or joint damage with plain film radiography.  Grading turf toe injuries involves interpreting signs and symptoms to assess tissue disruption.  Grade 1 sprain involves tenderness, minimal swelling, no ecchymosis and negative x-rays. (Churchill, 1998)  In this case the plantar capsule is stretched.  Grade 2 turf toe is a partially torn plantar capsule and the patient will have diffuse tenderness, moderate swelling, ecchymosis, and restriction of motion. (Churchill, 1998)  Grade 3 injuries have completely torn plantar capsules and may have a compression injury to the dorsal articular surface.  There will be severe tenderness, considerable swelling, ecchymosis and marked restriction in range of motion. (Churchill, 1998)

            Treatment for turf toe is very similar to other types of ligament sprains.  In the acute stages rest, ice, compression and elevation (R.I.C.E.) is an effective and conservative method to minimize inflammation in all grades of turf toe. (Churchill, 1998)  Grade 1 injuries can usually be taped to allow only for minimal extension of the great toe and limit dorsiflexion of the foot. (Nicholas, 1995)  Stiff-soled shoes or rigid orthotics with a Morton’s extension reduces motion of the first MTP joint to protect from re-injury. (Clanton, 1994)  Grade 2 injuries should avoid physical activities for 1 to 2 weeks, while grade 3 injuries should be sidelined for 3 to 6 weeks.  Grade 3 injuries may require surgery for capsule repair or removal of loose bodies. (Coker et al., 1978)  Non steroidal anti-inflammatory drugs and ultrasound can also be used in acute stages to reduce pain and inflammation.  Following the acute stages, it is essential to have a proper rehabilitation program to regain full range of motion and strength in the foot and ankle.  The strength and endurance of the foot can be addressed by using Therabands. (AthleticAdvisor, 2005)  The first MTP joint can be addressed by doing gentle range of motion exercises, and ultimately progress to more aggressive long-axis distraction manipulation to reduce the compression.  Such rehabilitation is crucial to prevent hallux rigidus, a painful progressive loss of motion in the first MTP joint. (AthleticAdvisor, 2005)  With hallux rigidus, patients report history of trauma, compression and repetitive hyperextension of the first MTP joint. (Churchill, 1998)  This may also ultimately result in degenerative arthritis of the great toe. (AthleticAdvisor, 2005) 

            In summary, turf toe is a fairly common injury seen in sports that are played on artificial turf, especially football.  This hyperextension injury of the first MTP joint has several predisposing factors, which includes increased flexibility, large shoes with many cleats, and of course the adoption of the less resilient turf.  Treatment for this capsular injury involves conventional R.I.C.E. methods and proper footwear, orthotics and taping to prevent further injury.  Rehabilitation is important to regain full function, and prevent future complications in the great toe. 

For more information Dr. Brent Moyer can be contacted at Brant Arts Chiropractic 905-637-6100. www.drbrentmoyer.com Twitter: @brantartschiro     Facebook: Brant Arts Chiropractic

 

 

References

 

            AthleticAdvisor (2005).  Turf-Toe.  http://www.athleticadvisor.com/injuries/LE/foot&ankle/turf_-_toe.htm

 

            Bowers K.D, (1976). Turf-toe: a shoe related football injury. Medicine Science and Sports Exercise. 8:81-83

 

Churchill, R.S., (1998).  Managing Injuries of the Great Toe. The Physician and Sportsmedicine.  Vol 26-9, Sept 98.

 

Coker, T.P. et al., (1978). Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. The American Journal of Sports Medicine. 6: 326-334.

 

Clanton, T.O., (1994). Turf Toe.  Clinics in Sports Medicine. 13, (4): 731-741.